By Johnnie Rosario
David Lubofsky wants the island's three major medical licensing boards to discipline the nurses, doctors, and respiratory therapists implicated by a federal report in the death of his son, Asher Dean Lubofsky.
Asher Dean was only five years old, when he died at 7 a,m. on October 31, 2018 at Guam Memorial Hospital. He was admitted the day before, and his condition worsened gradually over night. According to Mr. Lubofsky's previous statements to Kandit News, his son was never admitted to the ICU despite his deteriorating condition, the nurses never set him up with a breathing tube despite his labored breathing, and a doctor never checked on him through the night.
An investigative report on Asher Dean's death by the U.S. Centers for Medicare and Medicaid Services secretly published May 3, 2019 confirmed Mr. Lubofsky's statements, and more. Asher Dean is identified in the CMMS report as Patient 6.
"[T]he nurses failed to adequately monitor and use all available hospital resources for Patient 6," the report states. "Patient 6 had changes in respiratory status and vital signs over a period of time and he subsequently expired."
The report went on to detail the notes written into Asher Dean's chart during his stay in the Emergency Room, then the Pediatrics Unit. From his admittance at 11 a.m. on October 30 to his death the next day at 7 a.m., the boy was suspected of strep throat, pneumonia, and presumptive Dengue Fever. His fever, cough, chest congestion, facial color, and oxygen level became worse with each passing hour. His breathing became more labored throughout the night.
Mr. Lubofsky constantly asked the nurses on duty for a doctor to see his son, and for his son to be intubated so he could breathe and rest. The nurses, on the order of doctors whom they had called, gave the boy Albuterol and Tylenol for his symptoms.
The following are successive notes on Asher Dean's chart:
10:24 PM (October 30, 2018) - Patient refusing O2 via NC, Respiratory Therapist (RT) sets up O2 mist 28% on 6 Liter (L)
11:38 PM - Chest retractions, nasal Flaring, coarse crackles (an abnormal breath sound), head of bed elevated (HOB), face mask at 6 L
11:46 PM - Temperature (Temp.) 102.8, Tylenol given per order and cooling measures implemented
Notes over the next seven hours show the boy's life was slipping away as it became more difficult for him to breathe, blood began to secrete from his nares, his rash spread, and he began hallucinating. Still, no doctor came by his bedside.
6:53 AM (October 31, 2018) - Nurse checked patient noted and he is unresponsive with faint pulses. CPR initiated and code blue called - refer to code sheet
Still, no doctor called.
7:00 AM - Pulseless patient (Pt).
7:01 AM - Pt. intubated by ER MD, advance cardiac life support (ACLS) protocol followed, primary care physician (PCP) informed, intensive care unit (ICU) nurse and nursing supervisor present during code.
7:15 AM - Patient Asystole
7:16 AM - Time of death called by ER Doctor
Mr. Lubofsky reported these events to the Guam Board of Medical Examiners, the Allied Health Board, and the Guam Board of Nurse Examiners in 2019, but to no avail. At the time, there was no public record of what happened. He eventually filed lawsuits in the Superior and District Courts of Guam for the wrongful death of his son.
Over this past summer, Mr. Lubofsky caught a break. GMH was forced to disclose the May 3, 2019 CMMS report, which implicated the nurses, respiratory therapists, and doctors in the death of Asher Dean.
The report included summaries of the interviews with the medical providers, including two women who attended to Asher Dean, identified in the report as Respiratory Staff #8 and Respiratory Staff #9. Here are the summaries in the report:
During an interview on 4/30/19 at 9:00 a.m., with Respiratory Staff #8 she acknowledged that Patient 6 was experiencing respiratory distress and the VS were abnormal. She indicated that she reported every assessment and treatment to nursing. When asked if she considered calling the ED MD for an evaluation of Patient 6's respiratory status, since he was not responding to treatment, she stated 'No.'
During an interview concurrent with a record review on 4/30/19 at 4:30 p.m., with Respiratory Staff #9 she acknowledged that the respiratory status and VS documented in the flow sheets for Patient 6 were abnormal and not within the normal parameters. In addition Staff #9 further explained that continuous chest retractions, nasal flaring, coarse crackles, upgrading to various oxygen devices with no improvements post treatments and medications are serious signs of worsening of the respiratory distress status. When asked what would she consider for Patient 6 she stated 'placement of a breathing tube for the child would have been the best option.'
Based on the report, Mr. Lubofsky renewed his hope that Guam's medical licensing boards could evaluate the newly-available evidence and help to prevent wrongful deaths like Asher Dean's from happening again.
In two separate complaints to the Allied Health Board, Mr. Lubofsky wrote:
"The respiratory therapist on duty, as named herein, and within the CMS report (attached) was on duty. The CMS report just became available, hence the late filing of this complaint. My sons conditioned worsened all night as indicated in said report. I asked the nurses and the Respiratory Therapist (RT) many times, isn’t there a better way for him to breathe. They were using an oxygen mask, which he fought with me all night pulling it off. It was near impossible to keep it on him. The nurses and RT told me for my sons age 5, this was the only way they did it. I asked to tube him to breathe and they refused or repeated this is how we do it. This later, I learned, was not true and that a tube should have been done per the CMS report, protocol, and others. Also, with the worsening of my son's condition, with no improvement, the RT did not inform a doctor or supervisor or take any proactive measures as would be called for. Informing the nurses is not enough if that was even done. RT knew there was no intervention happening that was needed, she saw that no doctors ever entered my sons room and Asher’s condition was not raised to a higher level of treatment, such as ICU which she should have been involved in. It was as if she just ignored the situation. Why didn’t she tube him, why didn’t she call her RT supervisor, why did she not call the doctor when others did not as well? She knew he was dying. During the CMS interview, RT staff acknowledged the worsening of Asher’s condition and admitted that a breathing tube was what was needed. WHY DIDN’T IT HAPPEN? This shows clearly that the RT was functioning below the standard of care by not doing this and by not calling the doctor or her own supervisor and not doing any interventions to save Asher’s life. She also acknowledged to the CMS interviewer that she never thought to call the ER doctor. Is she even trained, calling the ER doctor is GMH standard protocol according to the doctor interviewed? This is her job to exhaust all resources, not to let my son die on her shift by taking the easy way. During the CMS interview she acknowledge the dire conditions and what she could have done."
Mr. Lubofsky added a note to the Allied Health Board:
"PLEASE NOTE, WE ARE REQUESTING A COMPLETE IMPARTIAL REVIEW THAT DOES NOT INCLUDE GMH EMPLOYEES OR RESPIRATORY THERAPIST FRIENDS TO PARTICIPATE WITH THE INVESTIGATION OR TO MAKE DECISIONS IN THEIR CAPACITY AS PART OF THE Allied Board.. SURELY, YOU CAN GET A REAL IMPARTIAL INVESTIGATOR. . PLEASE, WE HAVE BEEN THRU THIS BEFORE AND EXPECT AND HOPE TO BE INVOLVED IN THE INVESTIGATION AS A WITNESS AND NOT RELEASE THE RESULTS OF THE INVESTIGATION TO THE MEDIA BEFORE YOU INFORM US. AS NOTED,THE LATE DATE HAS TO DO WITH THE CMS REPORT BEING AVAILABLE NOW."